Dr. Rasheed comments on medical ethics and the Islamic principles and practices.

The 1991 census revealed that almost 6 percent of the UK population classified themselves as belonging to a minority ethnic group.  With no formal place for transcultural studies in either the undergraduate or postgraduate training of doctors, it is little wonder that clinicians face problems in tailoring care to the needs of minority ethnic communities.
Tracing its origins to the same Semitic soil that bore Judaism and Christianity, Islam continues to deeply influence the beliefs, values, and customs of an estimated one fifth of the human race.

God created man in the most perfect form.  Each human life has its own inherent value and goodness.  Humans however also have the capacity for autonomy and self determination and thus have the choice of pursuing a course of action that remain true to their innate pure state or following an immoral path.  Whilst genetic research and gene therapy may have positive uses in serving to restore health ( and in the process integrity), care must be taken to ensure that other Islamic principles are not violated.  An accurate and complete knowledge of one’s pedigree is a fundamental human right; only somatic cell lines should therefore be used in transplantation of genetic material since parental integrity is then not compromised and there is no question of hereditary characteristics being influenced.
Know your genealogy and respect your blood ties.
Children have the right to be born through a valid union (marriage) and to know their parentage fully.  Artificial insemination and in vitro fertilization are therefore licit only if sperm from the woman’s spouse is used.
Call the adoptive children by the name of their father.
Adoption is generally frowned on in Muslim culture since the process involves the transfer of parental rights to the adoptive parents.  Fostering is however positively encouraged since no similar transfer of parentage occurs.  In either case, the surname of the real father should be retained.

Prenatal screening and termination pregnancy
Each one of you will have had his created existence brought together in his mother’s womb, as a drop (nutfa) for forty days, then a leech like clot (alaqa) for the same period, then a piece of flesh (mughda) for the same period, after which God sends the angel to blow the spirit (ruh) into him.

On the basis of this text many Muslims conclude that fetal ensoulment occurs  120 days post-conception – an important consideration in discussions regarding termination of pregnancy.  First trimester chorionic villous biopsy ( performed before ensoulment) and advances in therapeutic foetal medicine may in time lead to a greater willingness to engage in genetic counseling and prenatal screening.
An existing life, with its responsibilities and ties, takes preference over a developing one.  If continuation of pregnancy places a mother’s life in danger then all Muslim authorities agree that termination of pregnancy is justified.  Termination for any other reason is strongly and consistently discouraged, particularly after ensoulment has occurred.

Child abuse, disciplining, and autonomy
The parent – child relationship is considered the most important of all human relationship, this forming a reference point for all other human encounters.  Both children and parents have mutual rights and responsibilities.  Love and respect are the guiding principles underpinning this most special of relationships.  Any form of sexual, physical, and emotional abuse of children is thus considered abhorrent within Islamic teachings, however, do recognize that children may at times need to be disciplined; both in their own interests and also in the interests of the wider society, and this may on occasions involve physical punishment.  In such instances, jurists have stipulated that the following conditions must be met: parents must never strike the face or head; minimal force should be used, and in particular, no bruising should result; disciplining should not be performed when parents feel they may lose control.

The 1989 Children’s Act states that age of consent is when a child reaches their sixteenth birthday, or younger, if a doctor deems a child capable of understanding and making decisions.  In Islamic law, the age of majority ( and hence full autonomy) is dependent on physiological maturation, this being defined for males by the first nocturnal emission and for females by menarche.

The end of life and brain death
Children are born pure according to the teachings of Islam, and those who remain true to their innate nature and abide by the teachings of Sacred Law, are considered whole or healthy.  If death is decreed we remind relatives that as children are pure they are assured of bliss in the eternal abode of the hereafter, and furthermore will be their forerunners in Paradise. Whosoever takes a human life, for other than murder or corruption in the earth, it is as if he has taken the life of all of mankind.

No one is authorized deliberately to end life, whether one’s own or that of another human being. Saving life is encouraged, and reducing suffering with analgesia is however acceptable, even if, in the process, death is hastened.  This rule is based on the central teaching that “ actions are to be judged by their intentions”. Withdrawal of food and drink to hasten death is therefore not allowed.

In 1987, Rahman, the US based Muslim philosopher expressed the view that relentless artificial prolongation of life is not in keeping with Islamic ethos unless there is evidence that a reasonable quality of life would result. The majority of Muslim authorities will consider “ brain stem” death acceptable grounds to discontinue life support therapy; three independent physicians, of whom at least one must be a neurologist, should however make the diagnosis.  A minority opinion is that the notion of brain stem death is inappropriate, for it is rooted in the Cartesian dualism that characterizes biomedicine.  It is argued that death criteria which remain true to the essence of the Semitic traditions, namely the point at which the soul departs, be identified and used for end of life decisions.

Withdrawing treatment from any patient, such as a child seriously affected by a hereditary neuromuscular disease, or curtailing treatment in a neonate with sever hypoxic encephalopathy, is never easy.  This decision is on occasions, however, somewhat easier for Muslim doctors, such as ourselves, when dealing with Muslim families with whom we share a common heritage and world view.  In such circumstances, after making clear that the child’s interests are our foremost consideration, it is often possible to make use of Islamic teachings in counseling parents regarding the difficult decisions that lie ahead.  We remind parents of God’s Omnipotence and the transient nature of our earthly sojourn in contrast to the abiding reality of the hereafter.  The exact time of death is a matter of Divine decree over which we as fellow human beings are ultimately bystanders.  In these situations we show guarded confidence, yet discuss the real possibility of worse to come, sometimes suddenly and catastrophically.  The ensuing “ dynamic dialogue” in which we engage is thus rooted in the individual and collective narrative of the family for whom wee provide care.

Postmortem examinations and organ transplantation
On the basis of Qur’anic text some scholars have deduced that it may be possible for the deceased to feel pain – one of the reasons for the general reluctance of Muslims to allow postmortem examinations.  Others, however, opine that the text obliges the Muslim community to deal humanely with fellow human beings whether in life or in death.  In future magnetic resonance necropsy may offer an alternative to formal open whole body postmortem examination. This innovation is becoming increasingly widespread in many pathology departments in the UK.

Organ transplantation is now encouraged in many Arab Muslim countries, and considered by some as a “perpetual” charitable act.  This issue has not been as well debated among the South Asian Muslim community, at least in part because until very recently the subject was only one of academic interest in these countries. Sale of bodily organs is categorically prohibited.  Xenotransplantation options are likely to increase in the foreseeable future and Muslim opinion about the acceptability and, if so, the prerequisite conditions (is transplant of organs from pigs acceptable when consumption of pork is forbidden?), remains divided.

Necessity allows the prohibited
But if one is compelled by necessity, neither craving nor transgressing – there is on him no sin, for indeed God is Clement, Merciful.
In the case of absolute necessity, where religiously lawful alternatives do not exist, Islamic teaching allows for Sacred Law to be suspended, temporarily if possible.  The use of pork insulin and heart valves from pigs has been ruled acceptable by many Ulema on the basis of this principle.

CONCLUSIONS
A minimum level of cultural awareness is a necessary prerequisite for the delivery of care that is culturally sensitive.  Once equipped with such understanding it is possible to move beyond the “recipe book” approach to dealing with minority traditions, offering the opportunity for experiential learning.  In this paper we have simplified and highlighted certain key teachings in Islamic medical ethics and explored their applications.  Though introductory, we hope that the insights gained will help clinicians to understand better their Muslim patients and deliver care that pays due respect to their beliefs.

Lastupdate on : Thu, 25 Mar 2010 21:30:00 Makkah time
Lastupdate on : Thu, 25 Mar 2010 18:30:00 GMT
Lastupdate on : Fri, 26 Mar 2010 00:00:00 IST